Chronic Hives Medical History Checklist Template

Chronic hives (chronic urticaria) are itchy, swollen welts that persist for six weeks or longer. Keeping a thorough medical history helps your healthcare provider pinpoint causes, rule out serious conditions, and customize treatment. Use this doctor-approved chronic hives medical history checklist template during your next visit or telehealth appointment.

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How to Use This Template

1. Print or copy into your notes app.
2. Complete each section before your appointment.
3. Bring any photos of flare-ups.
4. Share this checklist with your doctor to guide the discussion.

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A. Patient Demographics

• Full name, date of birth, age
• Contact information (phone, email)
• Preferred language / interpreter needs
• Height, weight, body mass index (BMI)

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B. History of Present Illness

• Date when hives first appeared
• Duration: continuous vs. intermittent
• Pattern: daily, weekly, seasonal
• Body areas affected (e.g., trunk, limbs, face)
• Onset: sudden vs. gradual
• Progression: stable, worsening, improving

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C. Symptom Characteristics

• Description of lesions:
  • Size (pinpoint to large patches)
  • Shape (round, ring-shaped, random)
  • Color (red, pink, skin-colored)
• Sensations:
  • Itchiness (mild, moderate, severe)
  • Burning or stinging
• Swelling: presence of deeper swelling (angioedema) around eyes, lips, hands, or genital areas
• Duration of individual welts (e.g., minutes, hours, days)
• Rate of new lesion development

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D. Triggers & Exacerbating Factors

Note any pattern or timing that seems to make hives worse:

• Foods eaten and timing of symptoms (e.g., shellfish, nuts, dairy)
• Medications started or changed recently (including over-the-counter)
• Physical factors:
  • Pressure (tight clothing, straps)
  • Temperature (heat, cold, sun exposure)
  • Exercise
• Stress levels or emotional events
• Infections: recent colds, flu, urinary or skin infections
• Hormonal changes: menstrual cycle, pregnancy
• New personal care products: soaps, detergents, cosmetics
• Environmental exposures: pollen, animal dander, insects

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E. Past Medical & Surgical History

• Allergies (food, medication, environmental)
• Autoimmune diseases (thyroid disorders, lupus)
• Chronic illnesses (asthma, eczema, diabetes)
• History of atopic conditions (eczema, hay fever)
• Surgeries and hospitalizations
• History of cancer or immunodeficiency

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F. Medications & Allergies

Current and recent treatments:

• Prescription medications (include dosage and schedule)
• Over-the-counter drugs and supplements
• Topical creams, antihistamine lotions
• Vaccinations within the last year
• List any known drug allergies and reactions

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G. Family History

• First-degree relatives with hives or autoimmune disorders
• Family history of allergies, asthma, eczema
• Genetic or hereditary conditions

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H. Social History

• Occupation and work environment (e.g., chemical exposures)
• Tobacco, alcohol, and recreational drug use
• Diet and exercise habits
• Pet ownership or animal contact
• Travel history (domestic and international)

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I. Previous Tests & Treatments

List all diagnostic steps and their results:

• Blood tests (complete blood count, thyroid function, ESR/CRP)
• Allergy testing (skin prick, RAST)
• Skin biopsies
• Imaging (if any)
• Previous treatments tried:
  • First-line antihistamines (non-sedating vs. sedating)
  • Higher-dose antihistamines
  • H2 blockers (e.g., ranitidine)
  • Corticosteroids (oral or topical)
  • Leukotriene receptor antagonists (montelukast)
  • Biologics (omalizumab)
  • Immunosuppressants (e.g., cyclosporine)
• Response to each treatment (none, partial, complete)
• Side effects experienced

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J. Impact on Daily Life

Understanding how chronic hives affect you helps tailor support:

• Sleep disruption: nights lost per week
• Work or school absenteeism
• Effect on mood, social activities, relationships
• Financial burden of medications and doctor visits
• Coping strategies you use (cool compresses, relaxation techniques)

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K. Physical Exam & Laboratory Data

(For healthcare provider to complete)

• Vital signs (temperature, blood pressure, heart rate)
• Skin exam:
  • Distribution and morphology of wheals
  • Presence of angioedema
• Signs of systemic involvement (joint swelling, lymphadenopathy)
• Recommended labs:
  • CBC with differential
  • Thyroid‐stimulating hormone (TSH)
  • Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
  • Complement levels (C3, C4) if angioedema is prominent
• Possible referral for dermatology or allergy/immunology

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L. Assessment & Plan

(For healthcare provider to complete)

• Working diagnosis (e.g., chronic spontaneous urticaria)
• Identified or suspected triggers
• Short-term management plan:
  • Adjust antihistamine dose or type
  • Add H2 blocker or leukotriene antagonist
• Long-term strategy:
  • Avoidance measures
  • Stress management techniques
• When to seek urgent care:
  • Severe angioedema affecting breathing or swallowing
  • Signs of infection (fever, spreading redness)
• Follow-up timeline and goals

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Next Steps & Resources

• Review this checklist with your doctor at the next appointment.
• Keep a daily symptom diary to track patterns.
• Before your appointment, use this free AI-powered tool to check your Hives (Urticaria) symptoms and get personalized insights to discuss with your healthcare provider.
• Always speak to a doctor if you experience severe swelling, difficulty breathing, chest pain, or any life-threatening symptoms.

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This chronic hives medical history checklist template empowers you and your healthcare provider to explore causes, monitor progress, and optimize treatment. Accurate, detailed information is key to finding relief and improving quality of life. Remember, if you ever feel your symptoms are serious or life-threatening, seek medical attention immediately.